About the Author
Rachel Prentice is Associate Professor of Science and Technology Studies at Cornell University.
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BODIES in FORMATIONAn Ethnography of Anatomy and Surgery Education
By RACHEL PRENTICE
DUKE UNIVERSITY PRESSCopyright © 2013 Duke University Press
All right reserved.
Chapter One"A FASCINATING OBJECT"
With some doctors, I get the feeling they're not seeing the part of me that's not my body. A PATIENT
Take my body. Use it well. Become a good doctor. TAKEN FROM A NOTE WRITTEN BY A FUTURE CADAVER DONOR TO MEDICAL STUDENTS
On the first day of a cadaver demonstration in an anatomy course I took, a student had to leave the laboratory because tufts of hair emerging from the cadaver's ears reminded her of her grandfather. In that moment, the cadaver became a former person, one who reminded the student of someone she loved. For her, the cadaver was no longer a scientific object. This phenomenon is common among medical students: some detail, such as ear hair or a tattoo, brings the cadaver's personhood to the fore, making dissection emotionally difficult. Students also often have strong emotional reactions when they dissect anatomical areas that evoke a cadaver's humanity and personhood, such as genitals, faces, and hands.
Cadavers are persons and things. This ontological duality cannot be resolved, but it can be managed through practices that encourage students to interact with cadavers as persons or as objects. Cadavers remain the most important objects-subjects in a formative rite of passage in North American medical schools: the anatomical dissection. Cadavers help students become physicians, in part by helping them shift from treating bodies as persons to treating bodies as the objects and the subjects of clinical inquiry. Although dissection as a pedagogical practice is in decline, most North American medical students still dissect cadavers in the anatomy courses they take in their first year. Defenders of dissection say the experience provides two benefits for medical students. First, dissection demonstrates a real, if not in vivo, example of the body's structures, and it helps students begin to develop a biomedical stance toward patient bodies. Second, it helps medical students to begin to craft their own bodies as practitioners while they craft others' bodies.
The cadaver often is a medical student's first exposure to medicalized human bodies, to bodily interiors, and to death. Students must grapple with the emotional intensity of destroying a human body. Dissection, whether it takes place in an anatomy laboratory or operating room, requires working against many ethical, legal, and religious traditions that prohibit doing damage to living and dead bodies. Several physicians I spoke with alluded to these taboos, saying what they do would be considered "psychopathic" in any other context. But medical and surgical education, as well as broader faith in biomedicine, makes dissection an important and accepted learning experience. In the past, students kept their feelings about dissection to themselves. Describing the anatomy course he took in the 1940s, Dr. Richard Hunt, a retired anatomist, said, "If you had weird feelings about the cadaver, you never dared tell anyone." Since the 1950s, however, anatomy programs have seen a steady rise in attention to students' affective socialization. Programs at the turn of the millennium do far more to give students opportunities to express their feelings and, in related ways, to engage in practices that summon the cadaver's personhood.
Biomedicine typically takes a "radically materialist" stance toward bodies, diseases, and treatments, approaching humans and their diseases as grounded almost exclusively in biology, excluding other explanatory frameworks (Scheper-Hughes and Lock 1987). Marilyn Strathern argues that biomedical physicians also seek, often in relatively impoverished ways, to "activate the person," who often gets erased amid biomedicine's objectifications of bodies and pathologies (2004, 8). In this chapter, I examine how anatomy training constructs cadavers as persons and as things. I also explore how anatomy courses manage student emotions, how students respond, and how similar constructions of patient bodies as persons and things come into play in clinical settings. Finally, I draw upon anthropological literatures on embodiment and emotion to connect medical training to the cultivation of an affective stance toward patients and their bodies. Students in anatomy laboratories learn to treat bodies within a materialist paradigm, while also cultivating means of engaging the patient's personhood. In other words, students learn to put the cadaver's ontological duality at the heart of what I call "tactical objectification," the ability to objectify the body or call forth the person as needed.
Objectivity and Objectification in Biomedicine
By the early 2000s, many medical schools had cut their anatomy curriculum from a year or more (which was common in the 1950s) to a semester or even a few weeks. Medical school administrators argue that cutting anatomy teaching has enabled them to make room in the packed curriculum for more leading-edge sciences. They also chafe at the cost of running a willed-body donation program that provides medical schools with teaching cadavers. During eighteen months of fieldwork from 2001 to 2006, I interviewed anatomy instructors at four medical schools, took a summer anatomy course, and did participant observation of anatomy courses, dissections, and other activities in two laboratories. Even among programs that remained most committed to traditional anatomy teaching, anatomists and technology builders often discussed the reduction or elimination of dissection at other schools, debated the merits of dissection versus demonstration with previously dissected materials, and considered how they could use imaging and modeling technologies to replace or supplement dissection. The threat to dissection as a pedagogical practice raises questions about what lessons, beyond knowledge of anatomical structures, the dissection holds for students.
Many nonphysicians I spoke with worried that biomedical training alienates physicians from their patients' humanity and that virtual anatomy or virtual dissection might further distance physicians from their patients. They expressed concern that a physician's sense of touch, empathy, or morality might remain underdeveloped without the experience of dissection. Physicians expressed concerns about the effects on medical students of reducing the hours spent dissecting or of eliminating dissection altogether. They argued that trainees must prepare themselves for the emotional rigors of clinical work and acquaint themselves with death and dead bodies.
There is something paradoxical in the notion that future physicians should study dead bodies, however real, to understand their patients' humanity, but the history of medical and scientific objectification of bodies coexists with the "still present sense that the body and its parts are always more than things" (Rabinow 1996, 149; see also Richardson 1987). Laypeople and physicians alike find significant ontological differences between "former" persons and scientific models ("never" persons), differences related to a cadaver's ongoing personhood. They see engagement with the cadaver's personhood as vital to physicians' moral and emotional development. The cadaver is never just an object.
A growing literature in science studies shows that the construction of an object of inquiry often involves the simultaneous construction of the scientific self (Daston and Galison 2007; Knorr Cetina 2000; Turkle 1995). In contrast, the social science literature on dissection has focused primarily on the achievement of a practitioner's "objectivity," including students' attempts to detach their treatment of the clinical body from opinions and emotions, or on objectification of the patient's body, finding that medical education teaches practitioners to set aside the patient's personhood and treat only the body. Medical students in the 1950s learned the value of "detached concern," the belief that medical empathy requires professional distance (Fox 1988). One student, who performed his first autopsy in the 1950s, told the sociologist Renee Fox, "You have to overcome some of your emotion ... and learn to look at things objectively and scientifically" (1988, 68, ellipsis in original). "Objectivity" in this usage becomes a synonym for emotional detachment. This is consistent with widespread faith in the values of science, objectivity, and the containment of emotion, which was stronger in the mid-twentieth century than it is at the beginning of the twenty-first century. These students' views of objectivity clearly fit within the construction of objectivity at a time when researchers considered detachment from self to be necessary for effective scientific or clinical discovery (Daston and Galison 2007).
Fox updated her study of medical students in the 1970s, arguing that, during the intervening decades, physicians had become much more concerned with developing the proper values and ethics in relation to patients. By the 1970s, physicians no longer valued the "omnipotent" physician or an attitude of "detached concern." Similarly, an objective stance would be viewed with some regret as interfering with "feeling with a patient" (Fox 1988, 100). Though Fox does not identify historical shifts that led to this change, she describes the trainees of the 1970s as far more concerned with issues of justice, equity, and resistance to the negative socializing effects of the medical "System" (96). Just a few years later, Donald Pollock (1996) found that so many students described their struggle to retain their humanity and empathy, despite "the System," that this belief itself seemed to be a hallmark of late twentieth-century medical education. He used physicians' autobiographies to suggest that stories about bucking the system reflected a concern with the rise of impersonal bureaucratizing and technologizing forces in biomedicine. He argued that the concern with resistance represented an essentially conservative appeal to values of individualism and moral responsibility, rather than a call for systemic reform (352). As Fox and Pollock show, the value of detachment in medicine came under increasing scrutiny in the latter half of the twentieth century as physicians sought to distance themselves from a medical system perceived to be dehumanizing and impersonal. The language of detachment remains ubiquitous in medical and social science depictions of medical training. Detachment does occur, but I have observed more nuance than these depictions convey.
Anthropologists have documented biomedical practices that construct the patient as an object (Good 1994; Hahn 1983; Scheper-Hughes and Lock 1987; Segal 1988; Young 1997). Scheper-Hughes and Lock (1987), for example, describe biomedical practitioners' pervasive separation of mind and body, which leads to the uniquely biomedical construction of disease as pathology contained in the patient's body, a construction that is not universally shared. They observe that the biomedical epistemology that objectifies patients' bodies is simultaneously effective and alienating. Looking at anatomy laboratories, Byron Good describes medical students struggling to alternate between seeing bodies as bodies in the anatomy laboratory and seeing bodies as persons when they leave (1994, 73). These discussions describe objectification as an often unfortunate product of the biomedical reductiveness that constructs ailments as discrete entities located in human tissues—that is, as objects.
In most of these discussions of the development of objectivity and of the objectification of bodies, the personhood of cadaver or patient, if mentioned at all, is construed as a threat to detachment and emotional control. While these authors' informants view empathy as desirable, they treat most emotions as negative or threatening states that training mitigates, either through the socializing effects of instructors and peers or the rationalizing effects of science itself. These views reflect European and North American cultural traditions that treat emotions as internal forces of irrationality and disorder that threaten reason and good judgment. "To be emotional is to fail to rationally process information and hence to undermine the possibilities for sensible, or intelligent action" (Lutz 1986, 291). This cultural bias shapes the view that emotional responses that go beyond compassion complicate good clinical practice, not least by clouding the practitioner's judgment.
The ontology of the body and the practitioner's emotional stance toward bodies and the persons who inhabit them clearly relate, but not in simple ways. Do patients or practitioners benefit from a practitioner's emotional detachment or from the objectification of a patient's body? Are the benefits of detachment or objectification clinical, emotional, or both? Answers to these questions are diverse: for every patient who wants an empathic physician, another wants clinical reserve. And for every physician who prizes his or her own detachment, another fears that too much distance may damage doctor-patient relations.
Charis Thompson (2005) studies patients in reproductive clinics to explore questions of agency and objectification of bodies. She finds that patients engage in complex practices of coordination of ontologies of their bodies as a means of managing the complex relations of technological fertilization to ideas of self, nature, and society. Thompson calls this use of objectification of one's body "ontological choreography." She says patients in in vitro fertilization clinics often objectify their own bodies. They say, for example, "My ovaries are not cooperating" when a procedure fails. Conversely, they may take ownership, saying, for example, "I am pregnant" when a procedure succeeds (189). By extending Thompson's important finding to practitioners and training practices, I show how medical training promotes and strengthens practitioners' abilities to engage in similar forms of ontological choreography by teaching trainees to objectify bodies or to activate persons, as needed. Practitioners learn these responses to distance themselves or their patients from difficult or disturbing biomedical procedures or to appeal to their own or their patients' humanity or agency.
Thus, ontological choreography is a common psychological move to create distance through objectification or to create ownership through appeals to personhood. I argue that medical training teaches and reinforces the trainee's ability to objectify the body or activate the person as needed.
Persons and Things in the Laboratory
Many ethnographic discussions of laboratories show how they reconfigure natural phenomena by reconstructing them as scientific objects. Human bodies in the anatomy laboratory are no exception. I have visited anatomy laboratories in several schools, finding them tucked away, on dusty top floors or in dark basements, far from the prying eyes of curious visitors who might wander by. Objects in anatomy laboratories—rolling steel tables, blue body bags, scalpels, and skeletons—locate them as spaces for investigation of human biology, connecting them to clinical work and, in a broader sense, to scientific research. Laboratories are "enhanced environments," where objects are detached from their natural order and "upgraded" to become available on demand to researchers (Knorr Cetina 2000, 28). The cadaver is the primary object of inquiry in the anatomy laboratory and, although "upgrading" might not be the correct word for embalming, the process slows decomposition, changing the cadaver's relationship to time to allow deconstruction by students rather than digestion by microbes.
While I was doing research in the anatomy laboratory at Coastal University, I observed several anatomy classes, assisted with dissections, and spent an afternoon dissecting an elbow. The lab is new and technologically sophisticated, but otherwise typical. It occupies the basement of a steel-and-glass building housing biology laboratories and classrooms on upper floors. The laboratory space resembles an operating suite, where most work takes place within a restricted core surrounded by peripheral functions. This arrangement creates the effect of a progressive introduction to dissection. The basement houses a main anatomy laboratory, a receiving area for bodies that is closed to the public, an office that keeps its anatomical identity understated, and several faculty offices. When I was there, instructors, technicians, and other staff had coffee in the lunchroom every morning. The scene would have fit a corporate or office lunchroom, except that dusty Vesalius prints depicting cadavers in classical poses competed with the cat calendar on the wall. Dark humor, such as one technician's remark that, after spending the day preparing donated bodies, he was exhausted from "lifting dead weight all day," punctuated the quiet flow of business.
One enters the main laboratory area through double doors with signs restricting access to those authorized. At the time, three human skeletons held together with wires dangled from the wall and greeted visitors when they entered the antechamber. To the right of the skeletons was a trashcan lined with a red "biohazard" bag in front of a bank of heavy steel sinks stocked with gloves, scalpel blades, and soap. The anteroom led to an inner room holding the dissecting bays, each containing a small shelf for anatomical atlases and other books, a small chalkboard, cubbies for backpacks and coats, and a large steel dissecting table. Cadavers on the tables were shrouded in bright blue plastic bags when not in use. The colorful bags make the space look less sterile and forbidding, despite their contents. A powerful ventilation system sucks out most odors, but the laboratory retains a faint, pervasive odor of embalming fluids and cleaning materials underlain with a slight odor of organic tissues that other chemicals never quite erase. Generations of medical students have said the smell of embalmed tissue generates powerful memories of the anatomy laboratory that persist for decades (Fox 1988, 58).
At Coastal, teaching assistants and technicians often wore surgical scrubs in the laboratory. Instructors and most students wore street clothes, occasionally donning scrubs or white laboratory coats over the top to protect street wear from chemicals. Anyone who planned to touch a cadaver had to wear gloves, but clothing changes were optional. The laboratory thus began students' transition into clinical clothing and safety practices. This mix of medical and casual garb made the laboratory, like the medical school itself, a liminal zone between university and clinic.
Excerpted from BODIES in FORMATION by RACHEL PRENTICE Copyright © 2013 by Duke University Press. Excerpted by permission of DUKE UNIVERSITY PRESS. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of ContentsAcknowledgements ix
1. "A Fascinating Object" 33
2. Cutting Dissection 69
3. Cultivating the Physician's Body 103
4. Techniques and Ethics in the Operating Room 137
5. Swimming in the Joint 171
6. Enterprising Bodies in the Laboratory 199
7.The Anatomy of a Surgical Simulation 227